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Derrick's Incarceration

APPELLATE FORMA PAUPERIS

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TITLE 42 U.S.C. 1983
APPELLATE FORMA PAUPERIS
FORMA PAUPERIS
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ACTUAL BLANK IJR -- PETITION FOR JUDICIAL REVIEW

NUMBER: DIVISION: VERSUS 19TH JUDICIAL DISTRICT COURT PARISH OF EAST BATON ROUGE STATE OF LOUISIANA APPELLATE PAUPER MOTION COMES NOW, _______________________, appellant, in the above-styled cause and, pursuant to the provisions of > C.C.P. art. 5181 et seq., respectfully moves for leave to appeal in forma pauperis without prepayment of fees, costs or security given therefor. In accordance with > LSA-R.S. 15:1186 et seq., the plaintiff shall be required, when funds exist, to pay an initial partial filing fee of $116.00 or 20% of the average monthly deposits up to a maximum of $116.00 and thereafter prison officials shall be required to forward monthly payments of 20% of the preceding month's income credited to the appellant's inmate account until the entire filing fee is paid. Appellant hereby authorizes the Department of Corrections to withhold and forward to the Clerk of Court the initial and subsequent monthly payments. ___________________________________ Date: _____________________ Signature AFFIDAVIT IN SUPPORT OF REQUEST TO PROCEED IN FORMA PAUPERIS ON APPEAL I, ___________________________, declare that I am the appellant in the above entitled case; that in support of my motion to proceed without being required to prepay fees, costs, or give security therefor, I state that because of my poverty that I am unable to pay the costs of said proceeding or to give security therefor; that I believe I am entitled to redress. I further declare that the responses which I have made to questions and instructions below are true. 1. Are you presently employed? Yes ( ) No (X) INCARCERATED a. If the answer is yes, state the amount of your salary of wages per month, and give the name and address of your employer b. If the answer is no, state the date of last employment and the amount of the salary and wages per month which you have received. 2. Have you received within the past twelve months any money from any of the following sources? a. Business, profession, or form of self employment (hobby craft sales included)? Yes ( ) No ( ) b. Rent payments, interest or dividends? Yes ( ) No ( ) c. Pensions, annuities or life insurance payments? Yes ( ) No ( ) d. Gifts of inheritances? Yes ( ) No ( ) e. Any other sources? Yes ( ) No ( ) If the answer to any of the above is yes, describe each source of money and state the amount received from each during the past 12 months. 3. Do you own any cash, or do you have money and/or bonds in a checking or savings account? (Include any funds in prison accounts) Yes ( ) No ( ). If the answer is YES, state the total value of items owned. A. Drawing Account $ B. Savings Account: $ C. Cash: $ D. Bonds: $ E. Other (specify) 4. Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property (Excluding ordinary household furnishing and clothing) Yes ( ) No ( ) If the answer is yes, describe the property and state its approximate value. 5. List the persons who are dependent upon you for support, state your relationship to those persons, indicate how much you contribute toward their support. I declare under penalty of perjury that the foregoing is true and correct. I understand that a false statement or answer to any question in this affidavit will subject me to penalties for perjury and/or dismissal of my suit. I authorize the Department of Corrections to make payments from my account(s) in accordance with law. Date _____________________ _________________________ Signature of Appellant STATE OF LOUISIANA PARISH OF __________ __________, being first duly sworn and under oath presents that he has read, signed, and subscribed to the above and states that the information therein is true and correct. ___________________________________ Appellant's Signature Appellant's D.O.C. # Subscribed and sworn to before me this ___ day of _______, 200___. __________________________________________ Notary Public or other person authorized to administer oaths STATE OF LOUISIANA PARISH OF __________ _____________________, (name of person not a party to this suit--third party witness, such as a fellow inmate) being first duly sworn did depose and say that he is not attorney or appellant; that he knows appellant; and, knows his financial condition, and believes that he/she is unable to pay the costs of court in advance, or as they accrue, or to furnish security therefor. ___________________________________ Signature of Affiant Subscribed and sworn to before me this ___ day of _______, 200___. __________________________________________ Notary Public or other person authorized to administer oaths APPELLANT ACCOUNT STATEMENT (Certified Institutional Equivalent) I hereby certify that __________________________, inmate number ___________________, the appellant herein, has the following sums of money on account to his/her credit at ________________________, institution where he/she is confined: Prison Drawing Account: $__________________ Prison Savings Account: $___________________ A. Cash $_____________ B. Bonds $____________ I further certify that the average monthly deposits for the preceding six months is $____________ (The average monthly deposits are to be determined by adding the deposits made during a given month and dividing that total by the number of deposits made during that month. This is repeated for each of the six months. The average from each of the six months are to be added together and the total is to be divided by six. I further certify that the average monthly balance for the prior six months is $_________________ (The average monthly balance is to be determined by adding each day's balance for a given month and dividing that total by the number of days in that month. This is to be repeated for each of the six months. The balance from each of the six months are to be added together and the total is to be divided by six.) ___________________________________ __________________________________________ Date Certified Signature of Authorized Officer of Institution NUMBER: DIVISION: VERSUS 19TH JUDICIAL DISTRICT COURT PARISH OF EAST BATON ROUGE STATE OF LOUISIANA APPELLANT PAUPER ORDER Considering the appellant's application to proceed in forma pauperis; that the said application reflects the status of his eligibility as of the date of the signing of the form, the law and evidence being in favor thereof: IT IS ORDERED, that appellant's application to proceed in forma pauperis on appeal be and is hereby denied, and appellant is hereby ordered to deposit with the Clerk of Court for the 19TH Judicial District Court on behalf of the 1ST Circuit Court of Appeal, the initial filing fee of $116.00. IT IS ORDERED, that appellant's motion to proceed in forma pauperis is granted pursuant to law, for the purpose of the appellant filing fee. All prisoners granted in forma pauperis status shall be assessed and required to pay $116.00, the initial appellate filing fee, in amounts as set by > LSA-R.S. 15:1186, et seq. Appellant shall be required to pay an initial partial filing fee and thereafter, prison officials shall be required to forward monthly payments from the appellant's inmate account until the entire filing fee is paid. IT IS FURTHER ORDERED, that within 20 days from the date of this order or full payment of trial court costs, whichever is sooner, the appellant shall pay an initial partial filing in the amount of $___ to the Clerk of Court for the 19th Judicial District Court or the appeal may be dismissed by the First Circuit Court of appeal. It is the appellant's responsibility to pay the initial partial filing fee of the Court of Appeal, through the East Baton Rouge Parish, Clerk of Court's office. IT IS FURTHER ORDERED, that following the payment of all trial court costs, the appellant shall make monthly payments of 20 per cent of the preceding month's income credited to his prison account. Monthly payments shall be automatically forwarded to the Centralized Inmate Banking Section for the Louisiana Department of Public Safety and Corrections without further action by the appellant. IT IS FURTHER ORDERED, that following payment of the initial partial filing fee, Centralized Inmate Banking Section for the Louisiana Department of Public Safety and Corrections shall forward the monthly payment from the appellant's prison account to the Clerk of Court each time the amount in the plaintiff's prison account exceeds $10.00 until the appellant filing fee of $116.00 is paid. IT IS FURTHER ORDERED, a copy of this order shall be mailed to the appellant and to Sonya Brown, Centralized Inmate Banking Section of the Louisiana Department of Public Safety and Corrections. IT IS FURTHER ORDERED, that the Louisiana Department of Public Safety and Corrections remit the above ordered funds to the 19TH Judicial District Court, Collections Department, P. O. Box 1991, Baton Rouge, LA 70821, in accordance with law until all appellate costs are paid. SO ORDERED, this ___ day of _______, 2006, at ______________________, Louisiana. ___________________________________ JUDGE/COMMISSIONER, 19TH JUDICIAL DISTRICT COURT

I CAN VOTE WHEN I AM RELEASED AND I WILL!!!!!